| NPI | 1104175405 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IA G094270) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 209009740) |
| Enumeration Date | 2012-08-31 |
| Last Update Date | 2020-09-29 |